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Linköping University Post Print

Specific muscle stabilizing as home exercises for


persistent pelvic girdle pain after pregnancy: a
randomized, controlled clinical trial

Annelie Gutke, Jenny Sjödahl and Birgitta Öberg

N.B.: When citing this work, cite the original article.

Original Publication:

Annelie Gutke, Jenny Sjödahl and Birgitta Öberg, Specific muscle stabilizing as home
exercises for persistent pelvic girdle pain after pregnancy: a randomized, controlled clinical
trial, 2010, Journal of Rehabilitation Medicine, (42), 10, 929-935.
http://dx.doi.org/10.2340/16501977-0615
Copyright: Foundation for Rehabilitation Information
http://www.medicaljournals.se/jrm/

Postprint available at: Linköping University Electronic Press


http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-60189
Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after

pregnancy: a randomized, controlled clinical trial

Annelie Gutke, PhD, Jenny Sjödahl, RPT, Birgitta Öberg, PhD

Division of Physiotherapy, Department of Medical and Health Sciences, Linköping

University, SE-581 83 Linköping, Sweden

Short title: Stabilizing exercises as home training


Abstract

Objective: To investigate the efficacy of home-based specific stabilizing exercises

focusing on the local stabilizing muscles as the only intervention in the treatment of

persistent postpartum pelvic girdle pain (PGP).

Design: A prospective, randomized, single-blinded, clinically controlled study.

Subjects: Eighty-eight women with pelvic girdle pain were recruited 3 months after

delivery.

Methods: The treatment consisted of specific stabilizing exercises targeting the local

trunk muscles. The reference group had a single telephone contact with a physiotherapist.

Primary outcome was disability measured with Oswestry Disability Index. Secondary

outcomes were pain, health-related quality of life (EQ-5D), symptom satisfaction, and

muscle function.

Results: No significant differences between groups could be found at 3- or 6-month

follow-up regarding primary outcome in disability. Within-group comparisons showed

some improvement in both groups in terms of disability, pain, symptom satisfaction and

muscle function compared with baseline although the majority still experienced pelvic

girdle pain.

Conclusion: Treatment with this home-training concept of specific stabilizing exercises

targeting the local muscles was no more effective in improving consequences of

persistent postpartum pelvic girdle pain than the clinically natural course. Regardless of

whether treatment with specific stabilizing exercises was carried out, the majority of

women still experienced some back pain almost one year after pregnancy.
Journal of Rehabilitation Medicine; Annelie Gutke; Department of Medical and Health

Sciences, Division of Physiotherapy, Linköping University, SE-581 83 Linköping,

Sweden; annelie.gutke@liu.se

Key words: low back pain; postpartum; physical therapy; exercise therapy, pelvic floor;

specific stabilizing exercises; trunk muscles.


Introduction

Approximately 50% of all pregnant women experience lumbopelvic pain to some degree

during pregnancy (1). For the majority of women, this pain disappears within 3 months

after delivery (2). However, the pain is persistent postpartum for a substantial number of

women (3, 4) and in 7% the pain is severe (1). Of women with recurrent lumbopelvic

pain, 10 to 20% relate their first episode of pain to pregnancy (5, 6). Research aiming to

identify effective and early treatment strategies for persistent pregnancy-related

lumbopelvic pain is important. Recent studies demonstrated the importance of

subgrouping lumbopelvic pain (7-9). In this study we have chosen to focus on the

subgroup with pelvic girdle pain (PGP) (10) or PGP in combination with lumbar pain

(combined pain) since these groups were shown to have the highest impact on daily life

(9).

Dysfunction of load transfer in the lumbopelvic region has been raised as one possible

explanation to lumbopelvic pain (11). A theoretical model of lumbopelvic pain presents a

self-locking mechanism of the pelvic joints based on the principles of form closure and

force closure (12). The local stabilizing muscles, i.e. the transversely oriented abdominal,

the lumbar multifidus, and the pelvic floor muscles, are reported to play an important role

in load transfer in the lumbopelvic region (13-15). Likewise muscle dysfunction has been

associated with PGP (16).

It has been suggested that improving the activation pattern of the local stabilizing muscles

results in functional improvement in lumbopelvic pain patients (17, 18). Treatment that
includes specific stabilizing exercises for the local muscles is effective for women with

PGP during pregnancy using a home training approach (19). After pregnancy, Stuge et al.

(20) successfully used a treatment concept including training of the global and local

muscles, ergonomic advices, body awareness, and when indicated massage, mobilization,

and stretching. Home training, following introduction of the exercises by a

physiotherapist, is a common approach in the clinic settings for specific stabilizing

exercises. The aim of the present study was to investigate if home-based specific

stabilizing exercises focusing on the local stabilizing muscles are sufficient as treatment

for women with persistent postpartum PGP or combined pain.

Methods

Study Design

This was a prospective, randomized, clinically controlled study. The randomization

procedure took place after a baseline examination was completed and eligibility was

determined. The participants draw sealed envelopes (from the research physiotherapist) to

assign to the treatment group or the reference group. The research physiotherapists who

conducted the follow-ups were blinded to group assignments.

Study participants

Women with lumbopelvic pain were recruited from two geographical areas in Sweden

during May 2002 to December 2004 (area 1) and during April 2007 to August 2008 (area

2), respectively. In area 1, women with persistent lumbopelvic pain 3 months postpartum

belonging to an ongoing cohort study were identified (8). In area 2, midwifes identified
women with persistent lumbopelvic pain at the follow-up visit 8-12 weeks after delivery.

In both areas, the women were examined by one of two research physiotherapists.

Classification of the pain problem was based on an examination starting with a

standardized history. It was followed by mechanical assessment of the lumbar spine

according to the Mechanical Diagnosis and Therapy protocol (MDT) (21) and pelvic pain

provocation tests performed in the mentioned order; distraction test, posterior pelvic pain

provocation test, Gaenslen’s test, compression test, sacral thrust (22). To consider a

pelvic pain provocation test positive it had to reproduce the women’s familiar pain

regarding localisation and quality. The active straight leg raising (ASLR) test (4-point

scale, sum: 0-6) (23), hip rotation range-of-motion test, and a neurological examination

were performed. The clinical examination is reliable and has been described in detail

(22).

Inclusion criteria for PGP were ≥ 2 positive pelvic pain provocation tests, pain onset

during a pregnancy or within 3 weeks from delivery and pain located distal and/or lateral

to the L5-S1 area in the buttocks. In addition to the criteria for PGP, some women also

had pain localised in the lumbar region, centralization or peripheralization phenomenon

and/or pain/symptoms during repeated movements/positions of the lumbar spine

according to the classification of MDT. These women were considered to have PGP in

combination with lumbar pain (combined pain) and were also included. Exclusion criteria

were: systemic locomotor disease, a verified diagnosis of spinal problems in the previous

two months, a history of fracture, neoplasm, or previous surgery of the spine, pelvis, or
femur, insufficient Swedish language skills, treatment with specific stabilizing exercises

during the previous 3 months, and ongoing pregnancy. All participants received oral and

written information about the study before oral consent.

Intervention

The women assigned to the treatment group were instructed to exercise ≥ 2 times per day

and to perform each exercise with 10 repetitions. The training consisted of specific

stabilizing exercises and focused on the transversely oriented abdominal, the lumbar

multifidus, and the pelvic floor muscles (24). Specific stabilizing training model includes

principles of motor learning theory and consists of three stages: (1) local segmental

control, (2) closed chain segmental control, and (3) open chain segmental control; in the

present study with emphasize on daily activities. An individual program was made for

each woman and exercises were chosen among 15 standardized and predesigned

exercises. The level of the exercises was progressively increased during the treatment

period with the goal to reach stage 3. In addition to the home training, individual

guidance and adjustment of the exercise program were performed every second week by

one of two treating physiotherapists. To measure compliance with the training program, a

daily training diary was kept during the training period.

The women in the reference group had one telephone contact with a physiotherapist.

They received information about PGP and combined pain, including the fact that it is a

common problem during pregnancy and that it disappears within a couple of months
postpartum in the majority of the cases. They were instructed to resume their normal

activities.

Assessment

In addition to the clinical examination, all participants completed questionnaires and

underwent muscle function tests at inclusion approximately 3 months postpartum and

again 3, 6, 12, and 24 months later. In this paper, the 3- and 6-month follow-ups are

reported.

Questionnaires

Demographic data was collected at baseline, consisting of age, body mass index, physical

activity level (1-6; 6 = most active; 1-3 = manage all household duties, including

gardening and light physical activity; or 4-6: the aforementioned activities + exercises at

increasing intensity) (25), current physical exercise frequency (never/sometime per

month, 1-2 times/week, or >2 times/week) urinary leakage (yes/no), number of

pregnancies, and number of children. Additionally, questions regarding delivery and

pregnancy, i.e. weight of the newborn, breast feeding (yes/no), delivery mode

(vaginal/caesarean), injuries during delivery (yes/no), lumbopelvic pain during pregnancy

(yes/no), treatment of the lumbopelvic pain during pregnancy (yes/no), and postpartum

depressive symptoms measured with the Edinburgh Postnatal Depression Scale (26) were

evaluated at baseline.
Questions regarding symptom satisfaction (delighted to mostly satisfied or mixed to

terrible feelings) (27) and expectations of treatment (completely restored, quite improved,

not improved but to get some relief of the symptoms, or no expectations of being

restored) were collected.

The primary outcome measure was disability, based on the Oswestry Disability Index

(ODI) version 2.0 (28). Pain intensity was measured with a visual analogue scale (VAS)

(0-100 mm) for current pain and average pain during the previous week. Pain frequency

was also measured (always, day and night to several times per week, or occasionally to

never). The EuroQol instrument (EQ-5D and EQ-VAS) was used to capture the women’s

perceived health-related quality of life (HRQL) (29). Wellbeing was measured with VAS

(0-100 mm) having defined end-points (low value indicating high wellbeing).

Muscle function

Muscle function tests were performed to evaluate whether the treatment had targeted the

muscle function or not. No encouragement was given during the tests. The tests were

conducted as described below.

Pelvic floor muscles

The activity of the pelvic floor muscles was evaluated with surface electromyography

(EMG). The EMG activity was recorded with PeriformTM vaginal probe (Neen

HealthCare, Dereham, UK). EMG signals were collected with NeuroTracTM ETS (Verity

Medical LDT, Surrey, UK). A ground electrode and an amplifier were placed on the right
hip at the iliac crest in order to reduce noise from the recordings of the pelvic floor

muscles. The between-trial reliability has been found to be good to high for the probe

(ICC(3,1) = 0.80-0.98, CV = 9.6-19.5 %) (30). The woman was supine on an examination

bench with the legs extended. She was asked to contract her pelvic floor muscles as much

as possible for 5 seconds and then to relax for 5 seconds. This sequence was repeated 5

times.

Gait

The women were timed walking barefoot for a distance of 20 meters “at a comfortable

speed” on a horizontal floor (modified from Ljungqvist et al.) (31).

Hip extensors

Maximal voluntary isometric hip extension was measured by a dynamometer (Chatillon

CSD 500 strength dynamometer, Ametek, Largo FL, US) with a fixed sensor. A sling

was placed on the women’s thigh at the distal end of the femur and pulled in extension.

They were instructed to pull as hard as they could. Two training repetitions were

performed. The mean of the next 3 repetitions were used for analyses. Each repetition

consisted of 5 seconds work and 5-10 seconds rest. The procedure was performed on both

legs; all women started with the right leg.

Back flexors

Isometric endurance of the back flexors was tested with women in the supine position

with arms crossed over their chest, hips bent, and knees and feet apart. They were asked
to nod and to continue to lift their head and shoulders until the inferior angle of the

scapula was lifted from the examination bench, and to hold the position for as long as

possible (modified from McQuade et al.) (32). The time that the position was maintained

was recorded in seconds and the test was interrupted after a maximum of 120 seconds.

Back extensors

Isometric endurance of the back extensors was tested with women in the prone position

with arms crossed over the chest and the trunk horizontal and transversely outside the

examination bench. The pelvis and the lower legs were fixated to the examination bench

by straps and by the tester, respectively (modified from Biering-Sörensen) (33). The time

that the position was maintained was recorded in seconds and the test was interrupted

after a maximum of 120 seconds.

Statistical analysis

Power analysis was based on a cohort of postpartum women (8). With a beta level of 80%

and a difference between the groups in ODI of 10%, 21 participants per group were

required. Two-group comparisons were made with Student’s t-test for continuous data.

The Mann-Whitney U test was used for ordinal data and the χ2 test or, when appropriate,

the Fisher exact test was performed on nominal data. Within-group comparisons were

made with paired t-test for continuous data, the Wilcoxon signed rank for data on ordinal

level, and the McNemar test was used for dichotomous variables. Statistical significance

was set at an alpha level of 0.05. The statistical software package SPSS was used (version
17.0; SPSS, Inc., Chicago, IL). The Regional Research Ethics Committee approved the

study (Ö414-00, T018-07).

Results

Study sample

A total of 88 women were included in the study. Sixty-five (74 %) and 60 (68 %) women

completed the 3-month and 6-month follow-up, respectively (Fig.1). There were no

significant differences between groups from the two geographical areas at the baseline.

The age of the participants and weight of the newborn babies differed significantly

between the treatment group and the reference group (Table I). No differences could be

detected between the groups at the baseline regarding disability, pain intensity, pain

frequency, HRQL, or muscle parameters (Tables II and III). The severity of the PGP

measured with the ASLR test did not differ between the treatment group (median score 0;

range 0-2) and the references group (median 0; range 0-4)(P = 0.150). The only woman

who scored 4/6 (none scored 3) did not participate in any follow-up.

Of the 21 participants who were not included in the three months follow-up, a lower

proportion reported urinary leakage (2/21 (10 %) vs. 21/65 (32%) P=0.040), had less

number of children living at home (P=0.046), and had a lower proportion of cesarean

delivery (0/21 vs. 12/65 (18.5%) P=0.034) than the 65 included. The 26 participants who

were not included in the six months follow-up, were older than the 60 included (32 years

vs. 30; P=0.040). There was no difference in primary outcome (ODI) between women

included and women not included in the two follow-ups.


Intervention outcome

On average 5 (SD 3) physiotherapy sessions were performed and on average 7 (SD 3)

exercises were prescribed to the women by the treating physiotherapist. No woman

trained 2 times/day in average during their training period, 10 woman trained ≥ 1.5

times/day in average and 15 woman trained <1.5 times/day. Seven diaries were not

handed in. Seventy-eight percent of the women in the treatment group reached stage 3 in

the treatment program. Eight women in the treatment group received additional treatment

(acupuncture, transcutaneous electrostimulation, ultrasound treatment, massage, pelvic

belt) along with specific local stabilizing exercises.

Disability

For the primary outcome, ODI, no difference could be demonstrated between the two

groups at 3- or 6-month follow-up (P = 0.205; P = 0.358) (Table II).

Within-group difference for the ODI was shown for the treatment group at 3-month

follow-up. Both groups showed within group differences at 6-month follow-up compared

with baseline (Table II).

Pain, HRQL, and wellbeing

A significant difference in pain frequency was demonstrated between the two groups at

the 3-month follow-up (P = 0.011) in favor of the treatment group. Pain was experienced

“always, day and night to several times per week” in 87% of women in the reference
group and in 58% of women in the treatment group. No differences could be detected

between the groups regarding pain intensity, HRQL or wellbeing (Table II).

Within-group comparisons showed that the pain intensity had decreased in the two

groups both at 3- and 6-month follow-up compared with baseline (Table II). The pain

frequency decreased in the reference group at the 6-month follow-up compared with

baseline (P = 0.022). Fifty-nine percent in the reference group experienced pain “always,

day and night to several times per week” at the 6-month follow-up compared with 87% at

the baseline (in the treatment group 54% vs 79% at baseline (P = 0.180)).

Symptom satisfaction

No differences were found between the two groups regarding symptom satisfaction at 3-

or 6-month follow-up (Table II). The treatment group had improved symptom satisfaction

(P = 0.039) at 3-month follow-up. Fifty-four percents were “delighted to mostly

satisfied” compared with 27% at the baseline. At 6-month follow-up, both groups had

improved symptom satisfaction. Sixty-three percent of the women in the treatment group

were “delighted to mostly satisfied” compared with 27% at the baseline (P = 0.001); in

the reference group 77% vs 33% at the baseline (P = 0.022).

Muscle function

A significant difference was demonstrated between the two groups for the mean hip

extension left at 3-month follow-up (P=0.047)(Table III). Within-group comparisons

showed an improvement in several of the global muscles measured but not the pelvic
floor muscles in both groups at the 3- and 6-month follow-up compared with baseline

(Table III).
Discussion

The main finding of this study was that the concept of home-based specific stabilizing

exercises focusing on the transversely oriented abdominal muscles, the lumbar

multifidus, and the pelvic floor muscles were no more effective in improving back-related

disability, HRQL, or reducing pain than the clinically natural course in women with

persistent postpartum PGP or combined pain.

A difference in pain frequency was demonstrated between the two groups at the 3-month

follow-up in favor of the treatment group. Based on within group comparisons, there

were tendencies in the same direction with the women in the treatment group rating the

disability and the consequences of their condition, lower at the 3-month follow-up

compared with baseline. This may be explained by the amount of comparisons done. It

may also be interpreted as a tendency that the group receiving specific stabilizing

exercises had a somewhat faster recovery than the reference group.

Previous studies found that treatment strategies including specific stabilizing exercises of

the local muscles postpartum were more effective than interventions without (20). Our

study differs from that performed by Stuge et al. regarding both the total concept and type

and dose of training. The training in our study focused mainly on the local stabilizing

muscles while Stuge et al. also included training of global muscles. Previous studies

showed that abdominal muscles, hip extensors, and back extensors are important muscles

in the production of force closure (34, 35). Our results suggest that there is no automatic
transfer between exercises of local muscles and improved function of the global muscles.

It might be wise to include exercises for local muscles as well as global muscles in

treatment strategies for PGP (20). This hypothesis is strengthened by the fact that women

with persistent postpartum lumbopelvic pain have decreased muscle function in the trunk

and hip muscles (16, 36).

Stabilizing exercises are reportedly more effective than other commonly prescribed

treatment in patients with classification of PGP (19, 20) or a specific back diagnosis (17).

In a review of non-specific low back pain (LBP), it was concluded that stabilizing

exercises alone or as a supplement to another therapy, reduced pain and disability (37).

However, there were great variations among the included studies, and the review did not

identify any convincing evidence that stabilizing exercises were superior to other

exercises.

The choice of stabilizing exercise as management for a patient should be based on

clinical findings indicating dysfunction of the stabilizing components. The ASLR test has

been suggested to assess load transfer in the lumbopelvic region as well as being an

indicator of severity of PGP (13, 38). The women in our study scored in median 0 out of

6 possible on the ASLR test at inclusion, indicating minor problem with load transfer in

the lumbopelvic region. The majority of women in our study might not have a load

transfer problem and accordingly is not expected to benefit from stabilizing exercises as

shown in women with higher score (20). Additionally, women with persistent postpartum

PGP but low scores on the ASLR test showed no difference in motor control pattern of
the pelvic floor muscles compared to healthy women (unpublished data1), which support

the assumption that the ASLR test is an indicator for load transfer problem. The results

on stabilizing exercises taken together indicate that subgroups of PGP as well as LBP

may benefit from stabilizing exercises. The challenge is to identify those subgroups.

The home-based approach makes it harder to control for compliance and exercise

frequency. It is possible that the home-training concept used in the present study for

stabilizing exercises do not give enough support to the women to reach optimal result.

Although Stuge et al.’s trial also used a home-based approach; their patients met with a

physiotherapist on average 11 times, which is more than twice as often as our women.

Regarding dose of exercises, our women were instructed to train twice or more per day

while Stuge et al.’s (20) patients trained 30 to 60 minutes 3 times per week. There was

also a difference in the length of the training period. It is possible that we could have

reached a different result with a longer training period. The most appropriate frequency-

response rate for achieving significant results is unknown; however these two studies on

postpartum PGP indicate that close support by a physiotherapist and at least a training

period of 20 weeks is needed.

Strengths of this study include that it is clinically generalizable, since women were

included from different geographical areas and more than one physiotherapist monitored

the training. However, there are also methodological limitations of the study. The women

1
Sjödahl J, Kvist J,Gutke A, Öberg B. The postural response of the pelvic floor muscles
during the active straight leg raise test in women with and without pelvic girdle pain
postpartum: an experimental study. Submitted
in our study had quite good functional status at baseline, limiting the possibility for

improvement. It should be considered that the women did not themselves seek medical

care. This means that individuals with minor problems are included, another difference

from Stuge et al.’s study. Additionally there was a 26 and 32 % loss of participants at the

3- and 6-month follow up, respectively which might have weaken our results.

Furthermore, the uneven randomization to the two arms where not possible to adjust for

when identified in the ongoing study.

In conclusion, no difference was found between treatment consisting of home-based

specific stabilizing exercises targeting mainly the local muscles and the clinically natural

course in women with persistent postpartum PGP or combined pain. Regardless of which

group the women were assigned to, the majority still experienced pain and some back-

related disability 9 months after delivery. It is possible that these women represent the

subset of patients that continue to experience recurrent episodes of lumbopelvic pain

throughout their lives (5, 6). It is of great importance to understand the effect of both

global and local muscles on lumbopelvic pain, in order to determine which subgroups of

LBP and PGP are suited for specific stabilizing exercises. It is possible that some women

need more than just training as treatment.

Acknowledgement: This study was supported by grants from The Swedish Research

Council, The Vardal Foundation, Foundation of the Region Västra Götaland, Trygg

Hansa Research Foundation, The Rehabilitation and Medical Research Foundation and

Linköping University, Sweden. The authors would like to thank the participants who
made this study possible. We would also like to thank the physiotherapists Kerstin

Johansson, Anette Edsberger and Lotta Berlin-Danielsson involved with the study

treatment. Henrik Magnusson for statistical support.


Table I. Descriptive data of all included women at baseline.

Treatment group Reference group Group comparisons

Variable P-values

Demographic data
Mean (SD) age in years 32 (4)1 30 (4) 2 0.041
1 2
Median no. of children living at home 2 (1-3) 2 (1-2) ns
(25th, 75th percentile)
Median no. of parity 2 (1-3) 1 2 (1-3) 2 ns
(25th, 75th percentile)
Median Body Mass Index 26 (23-28) 3 26 (24-28) 4 ns
(weight/height*2) (25th, 75 percentile)
Activity level last 3 months, n (%)
(1-6; 6 = most active)
1-3 = Manage all household duties, including 26 (79) 42 (81) ns
gardening and light physical activity
4-6 = The afore mentioned activities + exercise at 7 (22) 10 (19)
increasing intensity
Current physical exercise, n (%)
Never 5 (15) 6 (12) ns
Some time per month 4 (12) 4 (8)
1-2 times/wk 9 (27) 16 (31)
> 2 times/wk 15 (46) 26 (50)
Urinary leakage, n (%)
No 24 (73) 39 (74) ns
Yes 9 (27) 14 (26)
Data regarding pregnancy and delivery
Median score of the Edinburgh Postnatal 6 (2-8)5 7 (4-11)6 ns
Depression Scale (25th, 75 percentile)
Delivery method, n (%)
Caesarean 5 (18) 7 (17) ns
Vaginal 23 (82) 35 (83)
Mean (SD) weight of newborn in grams 3823 (585) 1 3512 (569) 2 0.016
Injury of the pelvic floor during delivery, n (%)
No 10 (31) 22 (42) ns
Yes 22 (69) 30 (58)
Lumbopelvic pain during pregnancy, n (%)
No 2 (6) 3 (6) ns
Yes 31 (94) 50 (94)
Received treatment of lumbopelvic
pain during pregnancy, n (%)
No 22 (71) 33 (66) ns
Yes 9 (29) 17 (34)
Currently breast feeding, n (%)
No 8 (26) 9 (17) ns
Yes 23 (74) 43 (83)
Expectations on treatment, n (%)
Completely restored or
quite improved 29 (88) 47 (92) ns
Not improved but some relief of the symptoms or
no expectations 4 (12) 4 (8)

1
n = 33; 2 n = 53; 3 n = 30; 4 n = 47; 5 n = 28; 6 = 44
P-values from Student’s t-test, Mann-Whitney U-test, Chi2-test or when appropriate, Fisher’s exact test
Significance level = 0.05
ns indicates not significant
Stabilizing exercises as home training

Table II. Between group comparisons and within group comparisons of ODI, Wellbeing VAS,
EQ-5D instrument and Pain intensity VAS based on mean differences at 3 and 6 months follow-
up. Symptom satisfaction and Pain frequency are presented as proportions at 3 and 6 months
follow-up.
Baseline 3-month 6-month
follow-up follow-up
Variable, median (25th, Treatment Reference Treatment Reference Treatment Reference
75th percentile) group Group Group Group group group
(n=32-33) (n=52-53) (n=25-26) (n=34-39) (n=23-24) (n=32-35)

Primary outcome

ODI Score % 18 (13-27) 18 (10-27) -4 (-14;2)* -2 (-6;4) -8 (-20;3)* -4(-12;2)*

Secondary outcomes

Wellbeing VAS 19 (10-35) 16 (11-32) -2(-9;11) -1.5(-10;6) 0 (-14;5) -3 (-14;4)


mm

EQ-5D 0.73 0.80 0.0 0.0 0 0.0


(0.70-0.80) (0.73-0.80) (-0.1;0.1) (0.0;0.06) (-0.1;0.1) (0.0;0.1)

EQ-VAS 79 (70-88) 77 (70-85) 5 (-1;10) 3 (-4;13) 4 (-2;11) 5 (0;12)*

Pain intensity VAS at 30 (13-48) 35 (17-55) -12 (-30;3)** -14 (-31;2)** -16 (-28;3)** -19 (-41;-1)**
moment mm

Pain intensity VAS 36 (23-50) 35 (20-59) -21(-34;6)** -14(-35;7)* -20 (-31;8)** -19(-48;0)**
average previous week
mm

Symptom satisfaction n
(%)
Delighted-mostly satisfied 9 (27) 17 (33) 14 (54)* 17 (44) 15 (63)* 27 (77)*
Mixed feelings-terrible 24 (73) 35 (67) 12 (46) 22 (56) 9 (38) 8 (21)

Pain frequency
Always, day and night- 26 (79) 45 (87) 14 (58)# 33 (87) 13 (54) 20 (59)*
several times per week

Occasionally-never 7 (21) 7 (13) 10 (42) 5 (13) 11 (46) 14 (41)

# between group comparison p<0.05


* within group comparison p<0.05
** within group comparison p< 0.001

23
Stabilizing exercises as home training

Table III. Between group comparisons and within group comparisons of the muscle function

tests based on mean differences


3-month 6-month
Baseline
follow-up follow-up

Treatment Reference Treatment Reference Treatment Reference


Variable,
group group group group group group
mean (SD)
(n=19-32) (n=35-52) (n=15-24) (n=16-37) (n=12-23) (n=17-35)
Muscle function
Back flexor endurance 31.1 (28.8) 32.3 (29.1) 2 (27.3) 0.8(15.2) 4.6 (23.5) 5.0 (27.2)
seconds
Back extensor endurance 51.6 (36.2) 40.4 (30.6) 6.6 (15.3) 20.4 (26.3)** 18.6 (14.8)* 17.3 (33.1)*
seconds
Gait speed meter/seconds 1.24(0.19) 1.28 (0.14) 0.07 (0.12)* 0.07 (0.12)** 0.08 (0.15)* 0.05 (0.16)

Mean hip extension right 210 (101) 203 (82) 41 (70)* 20 (57)* 35(60) * 28 (68)*
leg Newton
Peak hip extension right 249 (111) 250 (95) 41 (72)* 14 (63) 30 (733) 29 (80)*
leg Newton
Mean hip extension left 208 (94) 197 (82) 26 (54) * 2 (64)# 30 (41)* 8 (68)
leg Newton
Peak hip extension left leg 245 (103) 226 (84) 30 (70) 11 (60) 32 (43)* 18 (66)
Newton
Work average in the PFM 34 (20) 34 (22) 4 (14) 4 (17) 0.3 (20) 2 (13)
microvolt
Rest average in the PFM 9 (6) 8 (5) 0.2 (4.2) 0.3(4.5) -1.1 (4.3) -1.5 (4)
microvolt
Work peak in the PFM 71 (42) 70 (45) 4.8 (25.1) 0.6 (30.3) 1.7 (36.9) 2 (25.5)
microvolt
Average onset in the PFM 229 (174) 211 (337) 0.0 (0.2) 0.1 (0.6) 0.0 (0.2) 0.01 (0.21)
milliseconds

Average release in the 268 (518) 106 (610) 0.1 (0.4) 0.3 (0.8) -0.1 (0.4) 0.5 (0.9)*
PFM
milliseconds

Within group comparison:


# between group comparison p<0.05
* within group comparison p<0.05
** within group comparison p< 0.001

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Stabilizing exercises as home training

Enrollment

Recruited from area 1 Recruited from area 2


n = 59 n = 29

Totally recruited
n = 88

Randomization procedure

Allocated to specific stabilizing exercises group Allocated to reference group (n= 54)
(n= 34)
Allocation Received allocated intervention (n= 54)
Received allocated intervention (n= 32)

Did not receive allocated intervention (n= 2)

Lost to 3-month follow-up (n= 5) Lost to 3-month follow-up (n= 14)


 2 women were not able to attend the 3-  3 women were not able to attend the 3-month
month follow-up. follow-up.
 3 women did not want to continue to  9 women did not want to continue to participate
participate in the study. in the study.
 2 women were excluded due to new pregnancies.
Lost to 6-month follow-up (n= 5) Follow-up
 3 women were not able to attend the 6-
month follow-up. Lost to 6-month follow-up (n= 6)
 1 woman did not want to continue to  2 women were not able to attend the 6-month
participate in the study follow-up.
 1 woman was excluded due to new  2 women did not want to continue to participate
pregnancy. in the study.
 1 woman excluded due to spondylolisthesis  1 woman was excluded due to new pregnancy.

3-month follow-up analyse (n= 26) 3-month follow-up analyse (n= 39)

Excluded from analysis (n= 1) Excluded from analysis (n= 1)


 1 woman was excluded due to Analysis  1 woman was excluded due to
spondylolisthesis. pelvospondylitis..

6-month follow-up analyse (n= 24) 6-month follow-up analyse (n= 36)

25
Stabilizing exercises as home training

Figure legends
Figure 1 Participant flow through the randomized trial.

26
Stabilizing exercises as home training

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